Contraception

Introduction

Voluntary control of childbearing benefits women, men, and the children born to them. Contraception should be available to all women and men of reproductive ages. Education about contraception and access to contraceptive pills or devices are especially important for sexually active teenagers and for women following childbirth or abortion. 

1. Oral Contraceptives

Combined Oral Contraceptives

A. Efficacy and Methods of Use
Oral contraceptives have a theoretical failure rate of less than 0.5% if taken absolutely on schedule and a typical failure rate of 3%. Their primary mode of action is suppression of ovulation. The pills are initially started on the first or fifth day of the ovarian cycle and taken daily for 21 days, followed by 7 days of placebos or no medication, and this schedule is then continued for each cycle. If a pill is missed at any time, two pills should be taken the next day. A backup method should be used during the first cycle if the pills are started later than the fifth day. Low-dose oral contraceptives are no longer contraindicated in women aged 35-50 who are nonsmokers and have no risk factors for cardiovascular disease.

B. Benefits of Oral Contraceptives
There are many noncontraceptive advantages to oral contraceptives. Menstrual flow is lighter, resultant anemia is less common, and dysmenorrhea is relieved for most women. Functional ovarian cysts generally disappear with oral contraceptive use, and new cysts do not occur. Pain with ovulation and postovulatory aching are relieved. The risk of ovarian and endometrial cancer is decreased. The risks of salpingitis and ectopic pregnancy may be diminished. Acne is usually improved. The frequency of developing myomas is lower in long-term users (> 4 years). There is a beneficial effect on bone mass.

C. Selection of an Oral Contraceptive
Any of the combination oral contraceptives containing 35 ug or less of estrogen are suitable for most women. There is some variation in potency of the various progestins in the pills, but there are essentially no clinically significant differences for most women among the progestins in the low-dose pills. Women who have acne or hirsutism may benefit from use of one of the pills containing the third-generation progestins, desogestrel, drospirenone, or norgestimate, as they are the least androgenic. A combination regimen with 84 active and 7 inert pills, that results in only four menses per year (Seasonale), is now available. The low-dose oral contraceptives commonly used in the United States are listed in Table 17-5.

D. Drug Interactions
Several drugs interact with oral contraceptives to decrease their efficacy by causing induction of microsomal enzymes in the liver, by increasing sex hormone-binding globulin, and by other mechanisms. Some commonly prescribed drugs in this category are phenytoin, phenobarbital (and other barbiturates), primidone, carbamazepine, and rifampin. Women taking these drugs should use another means of contraception for maximum safety.

E. Contraindications and Adverse Effects
Oral contraceptives have been associated with many adverse effects; they are contraindicated in some situations and should be used with caution in others (Table 17-6).

1. Myocardial infarction
The risk of heart attack is higher with use of oral contraceptives, particularly with pills containing 50 ug of estrogen or more. Cigarette smoking, obesity, hypertension, diabetes, or hypercholesterolemia increases the risk. Young nonsmoking women have minimal increased risk. Smokers over age 40 and women with other cardiovascular risk factors should use other methods of birth control.

2. Thromboembolic disease
An increased rate of venous thromboembolism is found in oral contraceptive users, especially if the dose of estrogen is 50 ug or more. While the overall risk is very low (15 per 100,000 woman-years), several studies have reported a twofold increased risk in women using oral contraceptives containing the progestins gestodene (not available in the United States) or desogestrel compared with women using oral contraceptives with levonorgestrel and norethindrone. Women who develop thrombophlebitis should stop using this method, as should those at risk of thrombophlebitis because of surgery, fracture, serious injury, or immobilization.

3. Cerebrovascular disease
Overall, a small increased risk of Hemorrhagic stroke and subarachnoid hemorrhage and a somewhat greater increased risk of thrombotic stroke has been found; smoking, hypertension, and age over 35 years are associated with increased risk. Women who develop warning symptoms such as severe headache, blurred or lost vision, or other transient neurologic disorders should stop using oral contraceptives.

4. Carcinoma
A relationship between long-term (3-4 years) oral contraceptive use and occurrence of Cervical dysplasia and cancer has been found in various studies. A recent study has shown no increased risk of breast cancer in women aged 35-64 who were current or former users of oral contraceptives. Women with a family history of breast cancer or women who started oral contraceptive use at a young age were not at increased risk. Combination oral contraceptives reduce the risk of endometrial carcinoma by 40% after 2 years of use and 60% after 4 or more years of use. The risk of ovarian cancer is reduced by 30% with pill use for less than 4 years, by 60% with use for 5-11 years, and by 80% after 12 or more years. Rarely, oral contraceptives have been associated with the development of benign or malignant hepatic tumors; this may lead to rupture of the liver, hemorrhage, and death. The risk increases with higher dosage, longer duration of use, and older age.

5. Metabolic disorders
A decrease in glucose tolerance and an increase in triglyceride levels is seen in pill takers, and women with diabetes using this method should be carefully monitored.

6. Hypertension
Oral contraceptives may cause hypertension in some women; the risk is increased with longer duration of use and older age. Women who develop hypertension while using oral contraceptives should use other contraceptive methods. However, with regular blood pressure monitoring, nonsmoking women under the age of 40 with well-controlled mild hypertension may use oral contraceptives.

7. Headache
Migraine or other vascular headaches may occur or worsen with pill use. If severe or frequent headaches develop while using this method, it should be discontinued.

8. Amenorrhea
Postpill amenorrhea lasting a year or longer occurs occasionally, sometimes with galactorrhea. Prolactin levels should be checked; if elevated, a pituitary prolactinoma may be present.

9. Disorders of lactation
Combined oral contraceptives can impair the quantity and quality of breast milk. While it is preferable to avoid the use of combination oral contraceptives during lactation, the effects on milk quality are small and are not associated with developmental abnormalities in infants. Combination oral contraceptives should be started no earlier than 6 weeks postpartum to allow for establishment of lactation. Progestin-only pills, levonorgestrel implants, and depot medroxyprogesterone acetate are alternatives with no adverse effects on milk quality.

10. Other disorders
Depression may occur or be worsened with oral contraceptive use. Fluid retention may occur. Patients who had cholestatic jaundice during pregnancy may develop it while taking birth control pills.

F. Minor Side Effects
Nausea and dizziness may occur in the first few months of pill use. A weight gain of 2-5 lb commonly occurs. Spotting or breakthrough bleeding between menstrual periods may occur, especially if a pill is skipped or taken late; this may be helped by switching to a pill of slightly greater potency. Missed menstrual periods may occur, especially with low-dose pills. A pregnancy test should be performed if pills have been skipped or if two or more menstrual periods are missed. Depression, fatigue, and decreased libido can occur. Chloasma may occur, as in pregnancy, and is increased by exposure to sunlight.

Progestin Minipill

A. Efficacy and Methods of Use
Formulations containing 0.35 mg of norethindrone or 0.075 mg of norgestrel are available in the United States. Their efficacy is slightly lower than that of combined oral contraceptives, with failure rates of 1-4% being reported. The minipill is believed to prevent conception by causing thickening of the cervical mucus to make it hostile to sperm, alteration of ovum transport (which may account for the higher rate of ectopic pregnancy with these pills), and inhibition of implantation. Ovulation is inhibited inconsistently with this method. The minipill is begun on the first day of a menstrual cycle and then taken continuously for as long as contraception is desired.

B. Advantages
The low dose and absence of estrogen make the minipill safe during lactation; it may increase the flow of milk. It is often tried by women who want minimal doses of hormones and by patients who are over age 35. The minipill can be used by women with uterine myomas or sickle cell disease (S/S or S/C). Like the combined pill, the minipill decreases the likelihood of pelvic inflammatory disease by its effect on cervical mucus.

C. Complications and Contraindications
Minipill users often have bleeding irregularities (eg, prolonged flow, spotting, or amenorrhea); such patients may need monthly pregnancy tests. Ectopic pregnancies are more frequent, and complaints of abdominal pain should be investigated with this in mind. The absolute contraindications and many of the relative contraindications listed in Table 17-6 apply to the minipill. Exceptions are mentioned in section E, above. Minor side effects of combination oral contraceptives such as weight gain and mild headache may also occur with the minipill.

Preferences:
Marchbanks PA: Oral contraceptives and the risk of breast cancer. N Engl J Med 2002;346:2025.

Reproductive Health and Research; World Health Organization: Improving access to quality care in family planning. WHO/RHR 2000, Geneva.

Reproductive Health and Research; World Health Organization: Selected Practice Recommendations for Contraceptive Use. WHO/RHR 2002, Geneva.

Seibert C et al: Prescribing oral contraceptives for women older than 35 years of age. Ann Intern Med 2003;138:54.

------------------------

2. Contraceptive Injections & Implants (Long-Acting Progestins)

The injectable progestin medroxyprogesterone acetate is approved for contraceptive use in the United States. There is extensive worldwide experience with this method over the past 3 decades. The medication is given as a deep intramuscular injection of 150 mg every 3 months and has a contraceptive efficacy of 99.7%. Common side effects include irregular bleeding, amenorrhea, weight gain, and headache. Bone mineral loss may occur. Users commonly have irregular bleeding initially and subsequently develop amenorrhea. Ovulation may be delayed after the last injection. Contraindications are similar to those for the minipill.

A monthly injectable containing both depot medroxyprogesterone acetate and an estrogen, estradiol cypionate (Lunelle), has been available in the United States. It is highly effective, with a first-year pregnancy rate of 0.2% and a side effect profile similar to that of oral contraceptives.

The other long-acting progestin contraceptive is the Norplant system, a contraceptive implant containing levonorgestrel that is no longer available in the United States. The system consists of six small Silastic capsules that are inserted subcutaneously in the inner aspect of the upper arm. They release daily and provide highly effective contraception for 5 years. In the first year of use, Norplant is 99.8% effective. Contraceptive effectiveness drops slightly in succeeding years, but even in the fifth year it is more effective than the combination pill. The most common side effects include irregular bleeding and spotting, amenorrhea, headache, acne, and weight gain. Irregular bleeding is the most common reason for discontinuation. Hormone levels drop rapidly after removal of the implants, and there is no delay in the return of fertility. Contraindications are similar to those for the minipill. Insertion of the implants requires a minor surgical procedure under local anesthesia. Removal is also done under local anesthesia and may be more difficult than insertion. Removal may be facilitated by the “U” technique, involving use of a modified Vasectomy clamp through a 4-mm incision parallel to the implants between implants three and four.

Kaunitz AM: Injectable long-acting contraceptives. Clin Obstet Gynecol 2001;44:73. [PMID: 11219248]

Kovalevsky G et al: Norplant and other implantable contraceptives. Clin Obstet Gynecol 2001;44:92. [PMID: 11219249]

------------------------

3. Other Hormonal Methods

A transdermal contraceptive patch containing 150 ug norelgestromin and 20 ug ethinyl estradiol and measuring 20 cm2 is available. The patch is applied to the lower abdomen, upper torso, or buttock once a week for 3 consecutive weeks, followed by 1 week without the patch. The mechanism of action, side effects, and efficacy are similar to those associated with oral contraceptives, though compliance may be better.

A contraceptive vaginal ring that measures 54 mm in diameter and releases 120 ug of etonogestrel and 15 ug of ethinyl estradiol daily is available. The ring is soft and flexible and is placed in the upper vagina for 3 weeks, removed, and replaced 1 week later. The efficacy, mechanism of action, and systemic side effects are similar to those associated with oral contraceptives. In addition, users may experience an increased incidence of vaginal discharge.

------------------------

4. Intrauterine Devices (IUDs)

Introduction
IUDs available in the United States include the Mirena (which releases levonorgestrel) and the copper-bearing TCu380A. The mechanism of action of IUDs is thought to involve either spermicidal or inhibitory effects on sperm capacitation and transport. IUDs are not abortifacients.

The Mirena is effective for 5 years, and the TCu380A for 10 years. The hormone-containing IUDs have the advantage of reducing cramping and menstrual flow.

The IUD is an excellent contraceptive method for most women. The devices are highly effective, with failure rates similar to those achieved with surgical sterilization. Nulliparity is not a contraindication to IUD use. Women who are not in mutually monogamous relationships should use condoms for protection from STDs. The Mirena may have a protective effect against upper tract infection similar to that of the oral contraceptives.

Insertion
Insertion can be performed during or after the menses, at midcycle to prevent implantation, or later in the cycle if the patient has not become pregnant. Most clinicians wait for 6-8 weeks postpartum before inserting an IUD. When insertion is performed during lactation, there is greater risk of uterine perforation or embedding of the IUD. Insertion immediately following abortion is acceptable if there is no sepsis and if follow-up insertion a month later will not be possible; otherwise, it is wise to wait until 4 weeks postabortion.

Contraindications & Complications
Contraindications to use of IUDs are outlined in Table 17-7.

A. Pregnancy
A copper-containing IUD can be inserted within 5 days following a single episode of unprotected mid-cycle coitus as a postcoital contraceptive. An IUD should not be inserted into a pregnant uterus. If pregnancy occurs as an IUD failure, there is a greater chance of spontaneous abortion if the IUD is left in situ (50%) than if it is removed (25%). Spontaneous abortion with an IUD in place is associated with a high risk of severe sepsis, and death can occur rapidly. Women using an IUD who become pregnant should have the IUD removed if the string is visible. It can be removed at the time of abortion if this is desired. If the string is not visible and the patient wants to continue the pregnancy, she should be informed of the serious risk of sepsis and, occasionally, death with such pregnancies. She should be informed that any flu-like symptoms such as fever, myalgia, headache, or nausea warrant immediate medical attention for possible septic abortion.

Since the ratio of ectopic to intrauterine pregnancies is increased among IUD wearers, clinicians should search for adnexal masses in early pregnancy and should always check the products of conception for placental tissue following abortion.

B. Pelvic Infection
There is an increased risk of pelvic infection during the first month following insertion. The subsequent risk of pelvic infection appears to be primarily related to the risk of acquiring sexually transmitted infections. Infertility rates do not appear to be increased among women who have previously used the currently available IUDs. At the time of insertion, women with an increased risk of STDs should be screened for gonorrhea and chlamydiosis. Women with a history of recent or recurrent pelvic infection are not good candidates for IUD use.

C. Menorrhagia or Severe Dysmenorrhea
The copper IUD can cause heavier menstrual periods, bleeding between periods, and more cramping, so it is generally not suitable for women who already suffer from these problems. However, hormone-releasing IUDs can be tried in these cases, as they often cause decreased bleeding and cramping with menses. Nonsteroidal anti-inflammatory drugs are also helpful in decreasing bleeding and pain in IUD users.

D. Complete or Partial Expulsion
Spontaneous expulsion of the IUD occurs in 10-20% of cases during the first year of use. Any IUD should be removed if the body of the device can be seen or felt in the cervical os.

E. Missing IUD Strings
If the transcervical tail cannot be seen, this may signify unnoticed expulsion, perforation of the uterus with abdominal migration of the IUD, or simply retraction of the string into the cervical canal or uterus owing to movement of the IUD or uterine growth with pregnancy. Once pregnancy is ruled out, one should probe for the IUD with a sterile sound or forceps designed for IUD removal, after administering a paracervical block. If the IUD cannot be detected, pelvic ultrasound will demonstrate the IUD if it is in the uterus. Alternatively, obtain anteroposterior and lateral x-rays of the pelvis with another IUD or a sound in the uterus as a marker, to confirm an extrauterine IUD. If the IUD is in the abdominal cavity, it should generally be removed by laparoscopy or laparotomy. Open-looped all-plastic IUDs such as the Lippes Loop can be left in the pelvis without danger, but ring-shaped IUDs may strangulate a loop of bowel and copper-bearing IUDs may cause tissue reaction and adhesions.

Perforations of the uterus are less likely if insertion is performed slowly, with meticulous care taken to follow directions applicable to each type of IUD.

Preferences:
Grimes DA: Intrauterine device and upper-genital-tract infection. Lancet 2000;356:1013.

------------------------

5. Diaphragm & Cervical Cap

The diaphragm (with contraceptive jelly) is a safe and effective contraceptive method with features that make it acceptable to some women and not others. Failure rates range from 2% to 20%, depending on the motivation of the woman and the care with which the diaphragm is used. The advantages of this method are that it has no systemic side effects and gives significant protection against pelvic infection and Cervical dysplasia as well as pregnancy. The disadvantages are that it must be inserted near the time of coitus and that pressure from the rim predisposes some women to cystitis after intercourse.

The cervical cap (with contraceptive jelly) is similar to the diaphragm but fits snugly over the cervix only (the diaphragm stretches from behind the cervix to behind the pubic symphysis). The cervical cap is more difficult to insert and remove than the diaphragm. The main advantages are that it can be used by women who cannot be fitted for a diaphragm because of a relaxed anterior vaginal wall or by women who have discomfort or develop repeated bladder infections with the diaphragm.

Because of the small risk of toxic shock syndrome, a cervical cap or diaphragm should not be left in the vagina for over 12-18 hours, nor should these devices be used during the menstrual period (see above).

------------------------

6. Contraceptive Foam, Cream, Film, Sponge, Jelly, & Suppository

These products are available without prescription, are easy to use, and are fairly effective, with reported failure rates of 2-30%. All contain the spermicide nonoxynol-9, which also has some virucidal and bactericidal activity. Nonoxynol-9 does not appear to adversely affect the vaginal colonization of hydrogen peroxide-producing lactobacilli. Recent data suggest that nonoxynol-9 may not be protective against HIV infection, particularly in women who have frequent intercourse. The products have the advantages of being simple to use and easily available. Their disadvantage is a slightly higher failure rate than the diaphragm or condom.

Preferences:
Van Damme L et al: Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial. Lancet 2002;360:971. 

------------------------

7. Condom

The male sheath of latex or animal membrane affords good protection against pregnancy - equivalent to that of a diaphragm and spermicidal jelly; latex (but not animal membrane) condoms also offer protection against sexually transmitted disease and Cervical dysplasia. Men and women seeking protection against HIV transmission are advised to use a latex condom along with spermicide during vaginal or rectal intercourse. When a spermicide such as vaginal foam is used with the condom, the failure rate approaches that of oral contraceptives. Condoms coated with spermicide are available in the United States. The disadvantages of condoms are dulling of sensation and spillage of semen due to tearing, slipping, or leakage with detumescence of the penis.

A female condom made of polyurethane is available in the United States. The reported failure rates range from 5% to 21%; the efficacy is comparable to that of the diaphragm. This is the only female-controlled method that offers significant protection from both pregnancy and sexually transmitted diseases.

Preferences:
Rosen AD et al: Study of condom integrity after brief exposure to over-the-counter vaginal preparations. South Med J 1999; 92:305. [PMID: 10094272]

------------------------

8. Contraception Based on Awareness of Fertile Periods

Introduction
There is renewed interest in methods to identify times of ovulation and avoidance of unprotected intercourse at that time as a means of family planning. These methods are most effective when the couple restricts intercourse to the postovular phase of the cycle or uses a barrier method at other times. Women benefit from learning to identify their fertile periods. Well-instructed, motivated couples may achieve low pregnancy rates with fertility awareness, but in many field trials, the pregnancy rates were as high as 20%.

“Symptothermal" Natural Family Planning
The basis for this approach is patient-observed increase in clear elastic cervical mucus, brief abdominal midcycle discomfort ("mittelschmerz"), and a sustained rise of the basal body temperature about 2 weeks after onset of menstruation. Unprotected intercourse is avoided from shortly after the menstrual period, when fertile mucus is first identified, until 48 hours after ovulation, as identified by a sustained rise in temperature and the disappearance of clear elastic mucus.

Calendar Method
After the length of the menstrual cycle has been observed for at least 8 months, the following calculations are made: (1) The first fertile day is determined by subtracting 18 days from the shortest cycle, and (2) the last fertile day is determined by subtracting 11 days from the longest cycle. For example, if the observed cycles run from 24 to 28 days, the fertile period would extend from the sixth day of the cycle (24 minus 18) through the 17th day (28 minus 11). Day 1 of the cycle is the first day of menses.

Basal Body Temperature Method
This method indicates the safe time for intercourse after ovulation has passed. The temperature must be taken immediately upon awakening, before any activity. A slight drop in temperature often occurs 12-24 hours before ovulation, and a rise of about 0.4 °C occurs 1-2 days after ovulation. The elevated temperature continues throughout the remainder of the cycle. Data suggest that the risk of pregnancy increases starting 5 days prior to the day of ovulation, peaks on the day of ovulation, and then rapidly decreases to zero by the day after ovulation.

This fertility awareness method requires the use of a set of beads that reminds the couple to avoid intercourse (or use a barrier method of contraception) during days 8 through 19 of the menstrual cycle. The beads are in a circle and color-coded to show the days when a woman is likely to become pregnant and the days that are “safe” during the cycle. A movable ring is repositioned to a new bead each day starting on the first day of menses. In a small multicenter trial, the perfect use failure rate was 5% and the typical use failure rate was 12%. The method is applicable to women with a history of menstrual cycles between 29 and 32 days.

Arevalo M et al: Efficacy of a new method of family planning: the Standard Days Method. Contraception 2002;65:333.

Wilcox AJ et al: The timing of the “fertile window” in the menstrual cycle: day specific estimates from a prospective study. BMJ 2000;321:1259.

------------------------

9. Emergency Contraception

If unprotected intercourse occurs in midcycle and the woman is certain she has not inadvertently become pregnant earlier in the cycle, the following regimens are effective in preventing implantation. These methods should be started within 72 hours after unprotected coitus. (1) Levonorgestrel, 0.75 mg given in two doses 12 hours apart (available in the United States prepackaged as Plan B), has a 1% failure rate and is associated with less nausea and vomiting than the following combination regimen. A recent study has demonstrated that levonorgestrel, 1.5 mg as a single dose, given within 72 hours after intercourse, is slightly more effective than the two-dose regimen. It remains efficacious up to 120 hours after intercourse, though less so compared with earlier use. (2) Ethinyl estradiol, 50 ug, with 0.5 mg norgestrel (available in the United States prepackaged as Preven), given in a regimen of two tablets initially followed by two tablets 12 hours later. A comparable regimen includes four pills 12 hours apart of Lo/Ovral, Nordette, or Levlen, or the same regimen with the yellow pills of Triphasil or Tri-Levlen. The failure rate is approximately 3%, and antinausea medication should be provided. (3) Ethinyl estradiol, 2.5 mg twice daily for 5 days. This regimen is as efficacious as the others but is associated with a higher likelihood of nausea, vomiting, and breast tenderness. Mifepristone, 10 mg as a single dose, has been shown to have the same failure rate as the levonorgestrel regimen. It is not currently available at this dose in the United States.

IUD insertion within 5 days after one episode of unprotected midcycle coitus will also prevent pregnancy; copper-bearing IUDs have been tested for this purpose. The disadvantage of this method is possible infection, especially in rape cases; the advantage is ongoing contraceptive protection if this is desired in a patient for whom the IUD is a suitable choice.

Information on clinics or individual clinicians providing emergency contraception in the United States may be obtained by calling 1-888-668-2528.

Preferences
von Hertzen H et al: Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;360:1803.

------------------------

10. Abortion

Since the legalization of abortion in the United States in 1973, the related maternal mortality rate has fallen markedly, because illegal and self-induced abortions have been replaced by safer medical procedures. Abortions in the first trimester of pregnancy are performed by vacuum aspiration under local anesthesia. A similar technique, dilation and evacuation, is often used in the second trimester, with general or local anesthesia. Techniques utilizing intra-amniotic instillation of hypertonic saline solution or prostaglandins are also occasionally used after 18 weeks from the LMP but are more difficult for the patient. Abortions are rarely performed after 20 weeks from the LMP. It is currently believed that fetal viability is established at about 24 weeks. Legal abortion has a mortality rate of 1:100,000. Rates of morbidity and mortality rise with length of gestation. Currently in the United States, 90% of abortions are performed before 12 weeks’ gestation and only 3-4% after 17 weeks. If abortion is chosen, every effort should be made to encourage the patient to seek an early procedure.

Complications resulting from abortion include retained products of conception (often associated with infection and heavy bleeding) and unrecognized ectopic pregnancy. Immediate analysis of the removed tissue for placenta can exclude or corroborate the diagnosis of ectopic pregnancy. Women presenting with fever, bleeding, or abdominal pain after abortion should be examined; use of broad-spectrum antibiotics and reaspiration of the uterus are frequently necessary. Hospitalization is advisable if acute salpingitis requires intravenous administration of antibiotics. Complications following illegal abortion often need emergency care for hemorrhage, septic shock, or uterine perforation.

Rh immune globulin should be given to all Rh-negative women following abortion. Contraception should be thoroughly discussed and contraceptive supplies or pills provided at the time of abortion. In women with a past history of pelvic inflammatory disease, prophylactic antibiotics are indicated: A one-dose regimen is doxycycline, 200 mg orally 1 hour before the procedure, or aqueous penicillin G, 1 million units intravenously 30 minutes before. In the second trimester, use cefazolin, 1 g intravenously 30 minutes before the procedure. Many clinics prescribe tetracycline, 500 mg four times daily for 5 days after the procedure, for all patients.

Long-term sequelae of repeated induced abortions have been studied, but as yet there is no consensus on whether there are increased rates of fetal loss or premature labor. It is felt that such adverse sequelae can be minimized by performing early abortion with minimal cervical dilation or by the use of osmotic dilators to induce gradual cervical dilation. One population-based study showed no evidence of an increased risk of breast cancer in women who had undergone an induced abortion.

An FDA-approved oral abortifacient, mifepristone (RU 486), 200 mg as a single dose followed in 36-48 hours by a prostaglandin vaginally or orally, is 95% successful in terminating pregnancies of up to 9 weeks’ duration with minimum complications. The drug acts as an antihormone to progesterone and glucocorticoids without producing adrenal insufficiency. Although not approved by the FDA for this indication, a combination of intramuscular methotrexate, 50 mg/m2 of body surface area, followed 7 days later by vaginal misoprostol, 800 ug, was 98% successful in terminating pregnancy at 8 weeks or less. Minor side effects such as nausea, vomiting, and diarrhea are common with these regimens. There is a 5-10% incidence of hemorrhage or incomplete abortion requiring curettage, but there are no known long-term complications.

Preferences:
Creinin MD et al: Mifepristone and misoprostol and methotrexate/misoprostol in clinical practice for abortion. Am J Obstet Gynecol 2003;188:664.

Keder LM: Best practices in surgical abortion. Am J Obstet Gynecol 2003;189:418.

------------------------

11. Sterilization

In the United States, sterilization is the most popular method of birth control for couples who want no more children. Although sterilization is reversible in some instances, reversal surgery in both men and women is costly, complicated, and not always successful. Therefore, patients should be counseled carefully before sterilization and should view the procedure as final.

Vasectomy is a safe, simple procedure in which the vas deferens is severed and sealed through a scrotal incision under local anesthesia. Long-term follow-up studies on vasectomized men show no excess risk of cardiovascular disease. Several studies have shown a possible association with prostate cancer, but the evidence is weak and inconsistent.

Female sterilization is currently performed via laparoscopic bipolar electrocoagulation or plastic ring application on the uterine tubes or via minilaparotomy with Pomeroy tubal resection. The advantages of laparoscopy are minimal postoperative pain, small incisions, and rapid recovery. The advantages of minilaparotomy are that it can be performed with standard surgical instruments under local or general anesthesia. However, there is more postoperative pain and a longer recovery period. The cumulative 10-year failure rate for all methods combined is 1.85%, varying from 0.75% for postpartum partial salpingectomy and laparoscopic unipolar coagulation to 3.65% for spring clips; this fact should be discussed with women preoperatively. Some studies have found an increased risk of menstrual irregularities as a long-term complication of tubal ligation, but findings in different studies have been inconsistent. A new method of transcervical sterilization, Essure, has recently been approved by the FDA. The method involves the placement of an expanding microcoil of titanium into the proximal uterine tube under hysteroscopic guidance. The efficacy rate at 1 year is 99.8%.

Preferences
Kerin JF et al: The safety and effectiveness of a new hysteroscopic method for permanent birth control: results of the first Essure pbc clinical study. Aust N Z J Obstet Gynaecol 2001; 41:364.

Westoff C et al: Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000;73:913.

RELATED STORIES:
The risks and benefits of the combined oral contraceptive pill   Common breast problems   Adenomyosis: More common than you think   How is the Vaginal Opening Affected by Childbirth – And by Episiotomy?   Premenstrual Dysphoric Disorder   Sterilization   Pelvic Inflammatory Disease (PID; Salpingitis, Endometritis)   Vaginitis   Dysmenorrhea   Rape   Menopausal Syndrome   Infertility   Painful Intercourse (Dyspareunia)   Persistent Anovulation (Polycystic Ovary Syndrome)   Ovarian Tumors

Comments

[ + Post Your Own ]

Now you're in the public comment zone. What follows is not Armenian Medical Network's stuff; it comes from other people and we don't vouch for it. A reminder: By using this Web site you agree to accept our Terms of Service. Click here to read the Rules of Engagement.

There are no comments for this entry yet. [ + Comment here + ]